Basic Life Support & First Aid 2012

1. The purpose of this presentation is to introduce and refreshes some Basic Life Support (aka First Aid) principles, now based on the 2011 Australian Guidelines. This presentation was designed with health students in mind, as a refresher or in preparation for clinical placements. However, the topics covered here will be of use to anyone.

2. check for D anger S end for help check Response check Airways check for Breathing give CPR apply a Defibrillator

3. Check for Danger(Hazards/Risks/Safety?) to you to others to casualty For example; electrical wires, gases, aggressive relatives, water, etc. Remove yourself and the casualty to an area of safety Andy Field (Hubmedia) via flickr

4. Check the casualty for a response. Use the COWS Method Can you hear me? O pen your eyes What is your name? Squeeze my hand Gently squeeze shoulders(i.e. the trapezoid muscle)If casualty is unresponsive call for help.

5. Call 112 to reach emergency services virtually anywhere in the world. Call 911 for USA, 000 for Australia or notify your Cardiac Arrest team within the hospital. Image:

6. Check the airway is open and clear of obstructions. Use a head tilt, chin lift to open the airway. Use a jaw thrust for patients with suspected spinal cord, head, neck and facial trauma. (Usually done on patients with a GCS < 8.

7. In an unconscious patient, the tongue is the most common cause of obstruction. Also check the airway for blood, vomit & any other foreign materials. If breathing begins place in recovery position. Vassia Atanassova Spiritia

8. Look, listen and feel for breathing, up to 10 seconds. is chest rising and falling? can you hear or feel air from mouth or nose? In Australia it is no longer recommended to deliver rescue breaths but rather continue straight to CPR. In clinical situations use a face mask to administer the breaths. CPR should be the chief priority. image: c0d3in3 via Flickr

9. If no signs of life unconscious, not breathing and not moving, start CPR (cardiopulmonary resuscitation) CPR involves giving; 30 compression and 2 breaths 100 compressions per minute (useful tunes for compression The recommended point of rate are Staying Alive by the Bee Gees, Another one Bites the Dust compressions is the midline over to name a few) the lower half of the sternum.

10. Remember to push hard and fast, straight arms. Revival checks conducted every 2 minutes (look for pulse & signs of life) Should swap person doing compressions every 2min (so they dont become tired and perform ineffective compressions) 11. Doing CPR on Infants use two fingers instead of using hands You should check to deliver compressions. for vital signs every 2 minutes. Give 30 compression & 2 breaths 100 compressions per minute CPR should continue until the when delivering breaths do not overdo return of spontaneous the amount, as you may cause a lung circulation or you are relieved to rupture. by a qualified professional. 12. If Defibrillator is available, apply and follow voice prompts. Remember when shocking to get everyone to stand well back.

13. Note the next two slides are specific to allied health professionals and medical students. It is a reminder of some devices used for airway management. Oropharyngeal Airway Nasopharyngeal Endotracheal Laryngeal mask.

14. Once the Guedel or Nasopharyngeal airway is in place, Apply face mask, Use the resuscitator to provide ventilations, attach 15L of oxygen to resuscitator If performing ventilation manually ensure a tight seal between the mask and the face. Where possible have one person firmly holding the face mask down and the other ventilating.

15. BLS - whats coming up We shall now cover the following aspects of Basic Life Support. Care for Bleeding Care, for Shock, First Aid for Sprains & Strains Care, for Dislocations & Fractures, Poisoning, Burns, Diabetic Emergency.

16. 1. Apply Pressure to the Wound2. Raise and Support injured part3. Bandage Wound4. Check Circulation below wound5. If severe bleeding persists, give nothing by mouth & call emergency services/

17. 1. Assess Casualty (DRSABCD) 2. Call emergency3. Position Casualty, Keep the casualty lying down if possible. Elevate legs 10-12inches unless you suspect a spinal injury4. Treat any other injuries5. Ensure Comfort, Cover casualty to maintain warmth, Provide casualty with fresh air6. Monitor & Record breathing and pulse.

18. 1. Weak rapid pulse2. Cold, clammy skin3. Rapid breathing4. Faintness/dizziness5. Nausea6. Pale face, fingernails, lips.

19. RICER Ice, apply a cold pack. Do not apply ice directly to skin. Compress, use an elastic or comforting wrap not to tight. Elevate, above heart level to control internal bleeding.

20. Follow DRSABCD. Then precede with I A-C-T.I mobilize area. Use jackets, pillows, blankets and so on. Stop any movement by supporting injured area. Activate emergency services. Call 112 or 000. Care for shock. See care for shock slide. Treat any additional secondary injuries.

21. Follow DRSABCD & Check Materials Safety Data Sheet if possible. Signs & Symptoms Abdominal pain Drowsiness Nausea/vomiting Burning pains from mouth to stomach Difficulty in breathing Tight chest Blurred vision and so on.

22. 1. Remove Casualty from Danger (follow DRSABCD & remember STOP, DROP & ROLL) 2. Cool the burnt area (hold burnt area under cold running water for a minimum of 20 minutes.)3. Remove any constrictions (e.g. clothing & jewelry) 4. Cover Burn (place sterile, non-stick dressing over burn) isafmedia via flickr5. Calm Casualty.

23. 1. Follow DRS ABCD2. Try to determine whether the individual is suffering from a high (e.g. thirsty) or a low (hungry) blood sugar.3. If you are unsure, then the best option is to give the person a sweet drink, as it is more important to maintain minimum blood sugar levels. isafmedia via flickr4. Monitor individual & wait for arrival of medical assistance.

24. Standard Precautions Standard Precautions are standard, safe work practices that are to be applied to all patients regardless of their known or presumed infectious status. Standard Precautions are particularly Standard Precautions include steps important in cases with: such as: Blood (including dried blood) hand washing All other body fluids, secretions and use of appropriate personal excretions (excluding protective equipment (eg. sweat), regardless of whether they gloves) contain visible blood management of sharps, and Non-intact skin immunization of health care Mucous membranes workers.

25. Notice/Disclosure Im not a Medical Professional or a Doctor. Anything that is mentioned in this presentation, I have learnt during my university studies or through certified training programs. This presentation is not a substitute for professional training or proper medical advice. Hope you enjoyed this presentation. Cheers, Aaron

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ACLS 2012 Update

Several things have changed in ACLS 2012 that are good to know when dealing with a Cardiac Arrest patient. 1. CPR -Its C-A-B not ABC

dont stop (Avoid interruptions) and no need for multiple interruptions, hard and fast 2 inch compression allow chest recoil 100 beats per minute Stayin Alive Watch the video if you havent seen it. Its actually pretty good. 2. Medications dont work but, we are still going to give some of them!

no longer giving atropine for PEA/Asystole epinephrine still used 3. Electricity works defibrillate early in VF

I have heard that compressions can be done during biphasic defibrillations without getting shocked if you have gloves on? 4. Airway make it quick and dont just rely on pulse oximetry

continuous capnography is now recommended ETCO2 normal 35-40 mmHg avoid excessive ventilation persistently low ETCO2 ~10 mmHg is usually a bad sign but an increase of 10 mmHg may mean ROSC (return of spontaneous circulation) 5. Post Arrest Hypothermia works

32-34 degrees C within 4 H cool for 24 hours works best for post V Fib arrest but, can be used for any cardiac arrest based on judgement 6. Vascular Access

old school style is to place a central line only need IV/IO central line only if IV/IO is not possible

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Common drugs used in the Emergency Room By Henry Feldman, 2001 (Edited by Lewis Nelson, MD) Routes of administration IV Intravenous administration is when the drug is given in liquid form directly into a vein. This is often done by placing a venous catheter to allow easy administration. IM Direct injection into the muscle, Often a painful mode of administration, and provides a slow route of absorption. PO By mouth (Per Orum). Typically intermediate between IM and IV in speed of absorption. (is this true?) PR Rectal administration (Per Rectum). The rectum is actually a very quick method of drug administration as the rectum is highly vascular. This route is often used in children. ET Certain drugs can be given down an endotracheal tube. The drugs are given at 2-2.5 times normal IV dose. Drugs are followed with a saline bolus of ~10ml. The acronym for drugs that can go down an ET tube is ALONE: A Atropine L Lidocaine O Oxygen N Naloxone (Narcan) E Epinephrine Drug List Lidocaine Lidocaine has 2 uses: It is a local anesthetic when injected subcutaneously (and it can be used

for a nerve block). It is also an antidysrhythmic drug when injected IV (used to treat cardiac dysrhythmias). Anesthetic preparations come in 2 forms: with and without epinephrine. The epinephrine is added to reduce absorption and prolong the effect. A classic question by the resident/attending is: What is the toxic dose when used as a local anesthetic (Answer: 5mg/kg for lidocaine without epi, and 7mg/kg with epi.) Epinephrine Epinephrine is a natural substance produced by the adrenal gland (a.k.a. adrenaline). Epinephrine is used in emergencies to stimulate the heart or to dilate the bronchial tree. Its use is limited by cardiac side effects. It is also mixed with lidocaine to prolong lidocaines effect and to control bleeding. Furosemide (Lasix) Lasix is a diuretic, which is given IV or PO, which causes the patient to produce more urine. This is often given to reduce the fluid overload in patients with congestive heart failure (a.k.a. CHF) or hypertension. Diazepam (Valium) Diazepam is a benzodiazepine that is used both as a powerful sedative and as an anticonvulsant for patients with seizures. You will see it used for alcohol withdrawal, cocaine toxicity, and status epilepticus (i.e. uncontrolled seizures). Diazepam may produce respiratory depression. Midazolam (Versed) Versed is a very powerful short acting benzodiazepine type of sedative and is used to sedate patients for painful procedures. Excessive dosing may produce respiration depression (when given i.v.) or coma. Haloperidol (Haldol) Haldol is a antipsychotic with powerful sedative properties. It is often used for patients who are acting in a psychotic manner. It should not be used to treat alcohol withdrawal or cocaince toxicity. In sufficient quantities it will render the patient unconscious. Succinylcholine Often called sux (pronounced sucks), it is a paralytic, resulting in total muscular paralysis. It will most often be used for rapid-sequence-intubation to make tracheal intubation easier and to allow the patient to be mechanically ventilated. It has no analgesic properities and paralyzed

patients see, hear and feel everything - like a zombie! - thus it is never used without sedation. Atropine Atropine is used for several purposes, including inducing the heart to beat faster (i.e. chronotropy) as well as an antidote for certain organophosphate poisonings. It is sometimes used as a drug for patients with severe asthma. It can also be dripped into the eyes to produce dilation of the pupil (although this is a different formulation). Can also be used to dry up respiratory secretions during procedures. Heparin Heparin is an anticoagulant used to prevent blood from clotting. It is used in patients suspected of having a myocardial infarction and to prep the syringe for an arterial-blood-gas for the same reason. Valproic Acid Valproic Acid is used as an anticonvulsant medication. It is not typically used in the emergency treatment of seizures, but toxicity can often be seen with seizure patients who have taken too much. Phenobarbital Phenobarbital is a barbiturate which is used either as a sedative and/or anticonvulsant medication. Pentobarbital Similar to phenobarbital but much faster acting and with a duration of effect. It is used as an anticonvulsant medication and to treat severe alcohol withdrawal. Often used in a continuous drip for patients who continue to seize.

Methylprednisolone (Solumedrol) Solu-medrol is a long acting corticosteroid. It is often used to prevent the recurrence of anaphylaxis after the epinephrine has worn off and for patients with asthma. It has a half-life of around 6 hours. Albuterol (Proventil) Albuterol is a bronchodilator, used in a nebulizer for asthma patients. Typically a drop (0.5 mg) of albuterol is suspended in saline and nebulized with oxygen. Often referred to as how many nebs the patient got.

Ampicillin/Sulbactam (Unasyn) This is an antibiotic (ampicillin) with the second compound added to prevent bacterial lactamases from working (which interfere with penicillins). This overcomes the antibiotic resistance acquired by many bacteria. Flouroscein This is a fluorescent dye used to stain the cornea to look for scratches or ulcers. Scratches and ulcers will selectively retain the dye, making them glow under the cobalt-blue light of an opthalmoscope. Ketorolac (Toradol) Ketorolac is a powerful NSAID, used for severe headaches, musculo-skeletal pain, kidney stones and inflammation. Morphine Sulfate Morphine is a powerful opiate (derived from opium and similar to heroin) that is used as a pain killer (i.e. analgesic). However, as a side effect it can suppress respirations. Naloxone (Narcan) Narcan is the antidote to opioids such as heroin or morphine. It is very rapidly acting and competes with the opioid for the opioid receptor. Be careful when administering this drug, as it may cause withdrawal in opioid tolerant patients. Prednisone Prednisone is a corticosteroid that is given for asthma and as an anti-inflammatory. A side effect of prolonged use is Cushings syndrome and often you may see tremors. Rocuronium Often called rock, it is a paralytic. Administration produces total muscular paralysis. It is most often used for rapid-sequence-intubation to make tracheal intubation easier and to allow the patient to be mechanically ventilated. It has no analgesic properities and paralyzed patients see, hear and feel everything and should never used without sedation. Pilocarpine Pilocarpine is dripped into the eyes to produce constriction of the pupil in patients with glaucoma. Dopamine

Dopamine is a mild pressor agent, which is administered IV to produce vasoconstriction and raise a patients blood presure.

Phenytoin (Dilantin) Dilantin is an anticonvulsant. As a side effect, when administered too fast, it can induce hypotension. N-Acetylcysteine (Mucomyst) Mucomyst is given in cases of acetaminophen toxicity (e.g. Tylenol). tPA Tissue plasminogen activator is a thrombolytic agent, used to lyse blood clots in patients with myocardial infarction (a.k.a. heart attacks), non-hemorrhagic CVAs (a.k.a. strokes) and PEs (a.k.a. pulmonary emboli). Thrombolytics can cause hemorrhage and should be used with care. Streptokinase Streptokinase is a thrombolytic (note: discovered here at NYU) made by Streptococcus bacteria which dissolves clots, similar to tPA (although through a different mechanism) Diltiazem(Cardizem) Diltiazem is a calcium channel blocker used to slow the heart down in patients with certain types of tachycardias such as atrial fibrillation. Metoprolol Metoprolol is a beta-blocker which is used to slow down the heart and lower blood-pressure. These drugs are not typically used in asthmatics, as they can induce bronchoconstriction. Atenolol Atenolol is a beta-blocker similar to metoprolol. Adenosine Adenosine (the A of ATP fame) is used as an antidysrhythmic to break certain cardiac dysrhythmias; it is often used in patients with supraventricular tachycardia. The half life of the drug is only a few seconds, and can often induce non-pathologic asystole (flat line on an EKG) for a few

seconds. Digoxin Digoxin (a derivative of the Foxglove plant) is a cardiac drug used to slow conduction through the heart, especially in cases of atrial-fibrillation. As a side effect it can produce various dysrhythmias including ventricular fibrillation and aystole. Metronidazole (Flagyl) Flagyl is an antibiotic used against anaerobic bacteria and certain parasites. As a side effect patients can become violently ill to their stomachs from consuming alcohol with Flagyl (similar to Antabuse) Vancomycin Vancomycin is the last ditch antibiotic, used for highly resistant bacteria. It is fairly toxic to the patient, and often is a hobsons choice to administer to a septic, shocky patient.

Trimethoprim/sulfamethoxazole (Bactrim) Bactrim is a sulfa class antibiotic and is often used in urinary tract infections. Ketamine A sedative often used in conjuction with other sedatives (such as midazolam or diazepam). Pepcid Pepcid is a systemic antacid (H2 blocker) which takes 30-45 minutes to take effect, but lasts for several hours. Similar to ranitidine (Zantac) and cimetidine (Tagamet). NS NS stands for Normal Saline, which is 0.9% Sodium Chloride, and is the usual fluid given to a patient who needs fluid due to dehydration. It is approximately isotonic. LR LR stands for Lactated Ringers, which is Normal Saline with other electrolytes. Due to the presence of the other electrolytes, there is a limit to how much can be administered within a specific period of time.

D5, D10, D25 and D50 The D stands for Dextrose, which is a stable form of glucose. This solution is given IV to give

the patient glucose. This is never given IM, as high concentrations of glucose cause tissue death outside the vasculature.

UPDATED BASIC LIFE SUPPORT (BLS) ADVANCE CARDIOVASCULAR LIFE SUPPORT (ACLS) 2012 AND 25 EMERGENCY ROOM DRUGS

By: Balderas, Anthony Jordan, D.